Crash Cart: Hospital and insurance bill coder battles, the three emergency treatment options, and Maryland’s longest ER waiting time

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This week: Coder battles are major cause of sky-high medical bills, a study examines emergency care facility options and Maryland ER wait is the worst in the nation. Join in as our editors discuss the week’s headlines.


The battle between hospital and insurance bill coders—not simply medicine itself—is shown to be a major factor behind America’s health care cost crisis

The uninsured and self-payers pay 2.5x more than the insured and 3x than those on Medicare. The story of Wander Wickizer, an unisured woman who was hospitalized for a subarachnoid hemorrhage, illustrates the issues—and why the same treatment could $356,884.42, $285,507.58, or maybe around $70,000. Original Article by The New York Times.

Ryan McKennon, DO: So much in the article it’s hard to know where to start. First, note that ICD codes were developed by the WHO for research and epidemiology. CMS decided to use them for billing purposes in 1979. These were never designed for individual patients or doctors and certainly were not designed to determine cost of treatment. As CMS (and commercial insurers) tried to curtail costs by not paying or decreasing payment for certain codes, doctors and hospitals tried to maximize coding to get paid for what they did. And the gaming continues in an endless cycle with patients caught in the middle.

William Sullivan, DO, JD: This has been a pet peeve of mine forever. There are a few potential solutions that aren’t that difficult to implement. First, states could force hospitals to post a list of prices for all potential charges on a public web site. If a patient is charged for something that isn’t on the list, the item would – by law – be noncollectable. The problem is that no one knows exactly what supplies are going to be needed before many types of medical care are provided – think surgery, emergency medical care, etc. Therefore it would be difficult for a patient to estimate potential costs for medical care. Second, medical providers could take an approach like most other service industries and charge a time-based approach. Providers get $X/hour depending on their specialty – including nurses, techs, etc. All hospitals get a set facility fee from each patient to cover costs of running the facility. Think about how things would change if lawyers or plumbers charged based on some constantly-changing arcane set of codes like medical providers use. Costs would skyrocket. Third, something that should be utilized in situations like this more often – just file a consumer fraud claim against the hospital for the charges. That would force the hospital to disclose all of its charges and if the hospital overcharged or charged for services it didn’t provide, the patient would likely get substantial damages from a jury … and in many states companies found committing consumer fraud have to pay the other party’s attorney’s fees. This would force the hospital to justify each and every charge with medical documentation rather than forcing the patient to decipher cryptic bills. I suppose a fourth way to avoid scenarios like this is to create a system of universal coverage, but the tax increases involved in funding such a system would be unpalatable for most.

Nicholas Genes, MD, PhD: It needs saying, every time: This is preposterous. All of it. The inscrutable and inconsistent fees. Hiding the codes while demanding payment. Forcing patients and their lawyers to interact with dozens of staffers but never getting answers. How is it that we can spend so much on administrative costs (twice what is paid in Canada) and have so little to show for it? Charge Transparency certainly seems like part of the solution – Ohio was set to mandate it in 2017 but (surprise!) the Ohio Hospital Association and others sued to block it. Brandeis said sunlight is the best disinfectant – but don’t tell the healthcare lobby, because they’ll find a way to charge you for that, too.


Baylor compares freestanding emergency departments, hospital-based emergency departments, and urgent care centers

A Baylor College of Medicine study compares three emergency treatment facility types according to utilization, price per visit, and types of care offered. Original Article by Baylor College of Medicine.

Ryan McKennon, DO: No surprise here. Urgent care is cheaper than hospital-based or free-standing EDs. Hospital-based and free-standing EDs cost about the same. That’s because they provide the same service in most cases, urgent cares do not. The reason to choosing a free-standing ED is not cost, but location and wait times generally.

William Sullivan, DO, JD: The conclusions in the study were obvious, but it was somewhat interesting to review the cost comparisons. I’m surprised that urgent care visits average only $170. That’s less than many physician office visits – although many urgent care centers are staffed by midlevel providers which may keep costs down. Even $2,200 for an average ED visit doesn’t seem as bad as many horror stories that you read on the internet – like the one above.


Maryland has the longest ER waiting times, an average of 30 minutes longer than the national average

A color grid by the  Maryland Institute for Emergency Medical Services Systems shows an overwhelming increase in yellow alerts, red alerts, and re-routes, pointing to system overload. Original Article by ABC.

Ryan McKennon, DO: Unfortunately the story doesn’t go into much info on the reason Maryland’s wait times are so long but it did mention the new global budget revenue system they are functioning under. I wonder how much this has to do with boarding times. The most concerning part is that the annual ER visits have gone down over the last four years while wait times have gone up. I wonder if the number of EDs has changed in that time period.

William Sullivan, DO, JD: It would be interesting to study whether the wait time increases in Maryland were correlated with the adoption of Maryland’s capitated payment system three years ago. Notice how the article mentions that the number of ED patient visits has declined for the last 4 years? When you pay someone for a bundled set of services regardless of how many patients they see, that just incentivizes them to see less patients. These are the types unintended consequences that commonly occur when clueless policymakers create laws on issues upon which they are ill-informed.

Nicholas Genes, MD, PhD: There’s two discussions here. One is that Maryland’s average wait time is 53 minutes – well above the national average of 22 min but not, you know, outrageous. If capitation is causing crowding and delays in some EDs, with a lot patients waiting 2 or 3 hours, well, that’s a problem. But then the author goes on to interview someone who waited 8 hours, and finds a nurse who noted a 13-hour wait. That is outrageous. It seems more like a fundamental breakdown in staffing or responsiveness, instead of a problem with bundled payments. Those are EDs that seem due for a sentinel event any day now…


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